Sepsis awareness, abnormal physiology and the deteriorating patient

Dr Simon Stockley, RCGP Clinical Champion for Sepsis

Sepsis is not only an issue for Secondary Care but General Practice too, with a mortality of 37000 p.a.2 and 70% of cases arising in Primary Care3 it is essential that GPs are fully engaged in creating a sepsis aware health care system and community. The RCGP held a multi-stakeholder summit in January the consensus report1 has just been published.

RCGP Sepsis Summit Consensus1 Key Areas for Development

• Education and Awareness
• Integration and Connectivity
• IT and Technology
• Measuring Success
• Leadership and accountability

There are multiple definitions for sepsis 4-6 and tools to “help” based on abnormal symptoms and deranged physiology. As the data used for these tools is based on hospital experience it is difficult to know if they have the same predictive value for a GPs’ undifferentiated population. All the definitions agree that abnormal respiratory rate, blood pressure and altered mentation are potentially bad signs, and where accompanied by possible infection and clinical concern a Suspicion of Sepsis is appropriate. GPs currently are good at recording temperature and pulse in sick patients but less good at recording the three features that help define sepsis7, this must change. National Early Warning Scores(NEWS)8 of 5 or more correspond well with different definitions for sepsis and are increasingly used by hospitals and ambulance services 9,10 to identify sepsis. GPs should consider using physiological values including respiratory rate to record and augment their assessment of a deteriorating patient. NEWS offers a structured way to carry this out.

Once a Suspicion of Sepsis is raised, the GP must communicate that concern to ambulance and secondary care colleagues effectively. Hospital and Ambulance Services already use NEWS as part of their language around the deteriorating patient. GPs may find using Suspicion of Sepsis and a NEWS of 7 is better understood than “Really unwell with a high temperature and a chest infection”. Consider using the language of our colleagues to communicate concern better and more reliably, even if the words are a bit foreign. NEWS is also being used by community nursing colleagues and care homes to establish baseline physiological condition for patients and changes from that baseline to empower escalation for clinician assessment. There will be an increasing need for GPs to understand NEWS its weaknesses and strengths even if its predictive value in the community has yet to be established.

GPs are in a pivotal position to lead and support the creation of a sepsis aware system but evidencing progress at a practice level remains a challenge given the relative rarity of cases. Sepsis training appears to be on the increase but needs to drive system design and organisation if the learning is to become embedded and make change. Audit and structured reflective practice of how infection/sepsis assessments and safety netting are recorded together with resulting actions may improve practice. The PRIMIS Feverish Child under Five audit tool allows clinicians to identify if they made assessments of relevant physiology when assessing young children and encourages Read coded entry of findings. Other tools to do this support this and reflection upon individual sepsis cases need to be developed.

Sepsis is a challenge for the whole health system, the hospital systems are improving and now the call is for GPs to play their part.

References:

  1. RCGP. RCGP Sepsis Summit Consensus Report: Royal College of General Practice, 2017.
  2. Health & Social Care Information Centre. Hospital Episodes Statistics. 2015.
  3. NHS England Cross Systems Sepsis Prevention Programme Board. Improving outcomes for patients with sepsis: A cross-system action plan,. In: NHS England, editor. London: NHS England,; 2015.
  4. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Jama 2016; 315(8): 801-10.
  5. The Sepsis Trust. GP Management of Sepsis Toolkit. London: The Sepsis Trust; 2014.
  6. Excellence NIfHaC. Sepsis: recognition , diagnosis and early management. In: Excellence NIfHaC, editor.: NICE; 2016.
  7. NCEPOD. Just Say Sepsis. In: National Confidential Enquiry into Patient Outcomes and Death, editor. London: NCEPOD; 2015.
  8. Royal College of Physicians. National Early Warning Score (NEWS) Standardising the assessment of acute-illness severity in the NHS. RCP,; 2012.
  9. Shaw J, Fothergill RT, Clark S, Moore F. Can the prehospital National Early Warning Score identify patients most at risk from subsequent deterioration? Emergency medicine journal : EMJ 2017.
  10. Silcock DJ, Corfield AR, Gowens PA, Rooney KD. Validation of the National Early Warning Score in the prehospital setting. Resuscitation 2015; 89: 31-5.

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